Tuesday, August 28, 2007

I'm taking a blogging break for several days and leave you with some poems written by doctors and nurses here that were presented at one of our Schwartz Center Rounds several weeks ago. They appear with the permission of the authors, and I will present others in the future. (Apologies to the poets if I made formatting errors.)

With all the talk on this blog and elsewhere about the business aspects of running a hospital, these poems and poets provide a fine reminder of the intensely personal aspects of health care. I hope you appreciate them and the sentiments presented.

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ENCOUNTER ON THE STAIRSBy Warner V. Slack, MD

Next to Children’s Hospital, in a hurryDown the stairs, two at a timeSlowed down by a family, moving slowlyBlocking the stairway, I’m in a hurryI stop, annoyed, I’m in a hurrySeeing me, they move to the sideA woman says softly, “sorry” in SpanishI look down in passing, there’s a little boyUnsteady in gait, holding onto an armHead shaved, stitches in scalpPatch over eye, thin and paleHe catches my eye and gives me a smileMy walk is slower for the rest of the day

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Silent BurialBy Janet Greene, RN

Loving in secret takes its toll.Afraid to discover my twisted soulwhich loves things without beauty,I close the door hoping to find shelter.Feeling the chill from the wind of people’s voices,I wrap my sweater to me,And tuck my hands carefully in the cuffs.Quietly I cherish someone others loathed to touch.Her mind grew like a crooked branch,And her laugh had a silly shrill.Restless eyes betrayed her childish spiritThat earned no wisdom over time.Distance keeps my secret even in death.May the earthGently bury my untidy companion,And let me mourn in peace.

In Memory of Bertha Ann, 1984

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EVENING OF LIFEBy Anupama Gangavati, MD

Inside the nursing homeIn a small cornerThere…I saw herEyes dark and dried of tearsWrinkled faceReflecting fatigueHer gray hair in a total messLike the evening of her life.

“I lost my best friend…of eighty years”She said“I hope my time will come soon”Overwhelmed, I got confusedDidn’t know how to reactI even lost my own smileAnd now,In my solitude,The silence of the nightSeems to be telling me somethingThat I hate to believePerhaps a sheer reality

And now,Those dark eyes haunt meAs I close my eyesAnd ask myself“Does old age bring miseries?”

And now,The silence of the nightLeaves me wonderingAnd just wondering….

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The Baby KillerSusan Lane, RN, MSN, MBA

Pain… searingBelly… throbbingThere is no baby.There will be no baby.Endometriosis.

I remember teaching some of youHow to be on call‘Not an architect, but a fireman be’.Round earlyBefore the familyWho willExpress their need and wantingTheir time usually after noonYou must grant, but can avoidBy,Rounding early

And the white cloudGranted’on Friday an easy eveningWith no calls,So much so that you tested your beeper,And Saturday evening and night,ShortenedBy an act of a cowardly congress,Made you arise early, to meetA womanAdmitted with deliriumPerhaps due to too much medication for painWho saidWhile tearing at her hair,(there is a witness, an intern enthralled)I am in pain and you withhold it from me,isn’t there an imbetween place with the medications…?Something between pain and confusionAnd we stood barriered,For she had this before done.But while tearing at her hair(straightened thoughBlack but now returned to not)said I have my lung cancer,And my breast disfiguredBut one of my daughters, has just been toldShe also, has a breast that must be removed,And another, who has been told,That both breasts mustBe removedAnd another who also mustSacrifice her uterus…And perhaps her breasts alsoFinding meaning…

I raised themAs best I couldI gave themMy all, and now there is thisOnly tearsAnd pain,And no imbetweenDaughters withNo breasts,No uterusAnd you withholdMy pain medication

And we can only listenAnd listenAnd she becomes more calmAnd she apologizesAnd she becomes calmAnd we listen.And she begins to healAnd because of the white cloud, andBecause of the easy evening,And because of a cowardly congress.

I go to church to singCorelliAnd I have time to think,Before seeing more patients.This is what we do,We listen, we take the timeAnd the Corelli.

So I won’t write of the callAbout the cats, biting toesThat 2 PercosetEvery 4 hoursCan’t healIt is the time,Un imbursed that the architect, nor the FiremanWishes to offer.

Thank God,For the timeFor the Corelli

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EmotionsBy Nagma KC, RN

With an inspiration to healEyes open up without much sleepRushing, off I go towards my journeyHeart full of love and carehands full of devine touchless load, alas! nomuch work there is,and so is hope

I try my best to healLessen the sorrow and erasethe inner soul with painEasy work it ain't,Emotionally drenching it is,My heart is filled with painSeeing the moans, and the groanshelplessness and shrill criesOh Lord! I whisperPlease Help Him/ Help HerDear God, I saytake away their sorrow,Oh Please! take away their pain

Doctors are called, medicines are givenEyes become teary and my heart heavyWhy is there so much pain, I askEveryday, every hour, every secondHazy my view becomesI quit! I sayA hand on my shoulderA smiling face, it's my colleagueIt's the NurseIt's okay she says,You can do it

With a new vision, off I goHelping again, the sick8 hours are gone, now is the timeMercy Lord, I survived I sayAnd, I healed and spread loveTired, sad, happyI leave for homeWill be back tomorrow, I sayWill do a better job, I dreamHelp us all, I prayDear God! Dear Lordtake away all sorrow and pain!

Monday, August 27, 2007

As noted below, I had a chance last week to attend a very informative conference in Iceland with representatives from the major hospitals and medical schools of the Nordic countries (Iceland, Sweden, Denmark, Norway, and Finland). The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.

An advantage of actually meeting with people who run such systems is that you get to hear some of the details that do not make it into the public discussions here. I thought I would share just one aspect with you. In so doing, please recognize that I make no apologies for or denials about the inadequacies of our own approach. I am just trying to relate aspects of theirs that might be overlooked.

So, the simple question I asked was this: When the parliament sets the national budget for health care, how does it decide how to much to allot? Here in the US, the "budget" that we set for health care is partially set by Congress (for Medicare) and by state legislatures (for Medicaid), but well over half of our health care budget is not set centrally, but results from thousands of decisions and transactions by multiple players in the system. I was curious to learn, in contrast, how a welfare state decides on the appropriate amount.

I did not get answers about each country, but a pattern began to emerge. Using Iceland as an example, the answer seems to be that the parliament uses, as a rough guide, a desire to maintain overall health care costs at a certain percentage -- 10 or 11% -- of GNP. The US, at 15% is viewed as too high. Other European countries, at under 10%, are viewed as too low.

I pursued the question further. Is this percentage based on a quantified assessment of the actual health care needs of the public, i.e., is it driven by public demand (e.g., a growing aging population)? No. Does it take into account the government's expectation for certain quantifiable levels of service quality, medical quality, or operational efficiency of hospitals and other parts of the system? No.

In essence, this appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.

I offer this not in criticism, but just as a useful reminder to those of us in the US. The managers of the Nordic hospital systems, once their single annual appropriation is handed down, make important decisions about what services to offer to the public and what services not to offer. They also respond to appropriation levels by determining service quality levels. In the face of inevitable limitations on the ability of the nation hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.

Of course, we make similar managerial choices here when we run hospitals. The difference is that we do so in response to a variety of price signals set forth by a meld of public and private payers. Also, we have the advantage of one factor not really present in Europe, philanthropy from generous donors who help us provide advanced diagnoses and treatments that would not otherwise be available to the public.

As I note above, I am not saying one is better than the other. Just different. I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

It is always heartening when one of our trainees moves along to a higher calling. Several years ago, Dr. Jeremy Weiss was a fellow in interventional radiology at BIDMC. He now has a highly regarded practice on the West Coast, but he also has a sidelight as a magician. Check out his site here, and watch some of the videos in the "gallery" section in particular. Also, read the provocative posting on his blog about the late Dr. Ofey.

Friday, August 24, 2007

--One of many outdoor sculptures in Reykjavik, this one by Ásmundur Sveinsson.

--Evidence of the direction of lava flow, seen on rocks throughout the country.

--A grave marker from years ago: To this date, each Icelander has a first name and then a last name based on his or her father´s first name. There are no last names. Phone books list people alphabetically by their first names.

--The side of a glacial valley, cut through volcanic rock. (All the rock here is volcanic.)

--Road and pipe leading from the geothermal energy plant that serves the capital city. Bore holes produce steam and hot water. The steam drives a turbine to produce electricity. The leftover steam and hot water then pass through a heat exchanger to heat cool water taken from a lake, which is then transported about 30 kilometers to Reykjavik, losing only 2 degrees Celsius en route. Geothermal energy is a key asset in Iceland´s economy.

An interesting idea from Ulleval University Hospital in Oslo. (There are some similar concepts that I know of from the US, like MIT´s Center for Biomedical Innovation and Entrepreneurship Center, but this one has its own unique features.) Here´s a summary from Andreas Moan, Director of Research and Education:

The Clinic of Innovation is run like any traditional out-patient clinic with one major difference: The purpose of this Clinic is to facilitate the conversion of ideas from research and medical practice into new services or products to the benefit of both patients and society. We also want to offer the same kind of service to ideas generated outside the hospital, offering our medical and research expertise. The Clinic of Innovation is organized as any other out-patient clinic, offering diagnostic work-ups, treatment and follow-up.

It is a joint venture between the Ulleval University Hospital and Medinnova, a Technology Transfer Office with 20 years of experience in innovation. The Clinic has two main customers: First, people working within the health system with new ideas on how services, treatment, organization or products can be improved or developed. Secondly, the Clinic acts as a bridge into the health system for people, commercial parties, biotech and other research-intensive businesses who may be looking for an initial point of contact to the public health sector.

Culture and language is quite different in the public health system and in private enterprise, and our goal is that the Clinic of Innovation may serve as a meeting point and as translators. Our employees have experience from both the private and public sectors.

Although this Clinic is organized as any other out-patient clinic, there is one major difference: To this Clinic you can refer yourself – please see below.

The Clinic of Innovation offers:

Diagnostic work-ups entailing evaluating your idea’s potential in both research and commercial context, or calling external competence as needed to do so. Depending on the diagnosis, the idea (and its owner) will be offered treatment that may entail- direct problem solving- development as a joint venture/active project- establishment of contact with new networks that we believe will help develop the idea- referral to group therapy with other innovators facing similar problems

Follow-up means seeing you and your idea back for follow-up and additional referral or problems solving as the idea evolves.

The Clinic of Innovation is also a tool to inform about the importance, possible economical impact and sheer pleasure of innovation. The tools for this activity include media coverage, advertising and visiting relevant people and communities inside and outside of the hospital.

How do you find the Clinic of Innovation?

Physically located at the Ulleval University Hospital in Oslo, Norway.

New ideas are best submitted by a webform located here Medinnova or by email or phone.

The Clinic of Innovations has weekly intake meetings, so you can expect an answer within no more than two weeks. We may want to contact you ahead of the intake meeting to better understand your concept. Your referral is guaranteed full confidentiality, confirmed on the return receipt you get on our referral form. We will also sign a confidentiality agreement at the first appointment.

Thursday, August 23, 2007

A quick progress note about the local scene. More on the conference later.

In Iceland, when you go to the pool for your morning swim and bath in "hot pots", you can rent a small locker, in which you can securely charge up your cell phone during your swim. You can pay for it with a coin or by text messaging to a certain number, after which the rental and charging fee will be deducted from your bank account. The locker has built into it three power cords with different connector attachments for the most popular cell phones, especially Nokia´s.

(Cell phones can also be used to pay for parking in municipal lots by text messaging.)

By the way, the pools are public and are considered an essential public service, right after schools, so every municipality has a least one. The water is heated geothermally, and people swim outdoors all year long, and it is a regular routine for many. The pool was comfortably warmer than the air on a cool 50 degree Farenheit morning. The hot tubs are ranked by temperature, starting at 38 degrees Celsius and rising in two degree increments from there. I felt a bit like the proverbial frog in a slowly heated pot of water as I went from one to the next. At 42 degrees, you really are fully cooked.

Wednesday, August 22, 2007

I am in Iceland (yes, Iceland) for a couple of days to give a talk at a conference -- more on that in a moment -- and I was reading an article about Icelandic shrimp in Atlantica, the Icelandic Air airplane magazine. I ripped it out at the time because I thought it was interesting but didn´t think about it again until tonight when I was eating some of those exact shrimp at a reception.

It appears that there is a carbohydrate -- chitosan -- derived from the exoskeletons of Icelandic shrimp that is applied to bandages that have a high success rate in external hemorrhage control in combat operations. According to this article, the company that makes them is based in Oregon and is called HemCon and has apparently sold more than 400,000 bandages to the US Army.

The good news is that the bandages help. The bad news, of course, is that they are needed by our armed forces and by civilians in war zones. (Before anyone asks, I do not know if BIDMC or any of our faculty ever have had any financial relationship with this company -- and I have not had a chance to check with our folks in Boston, so I can´t find out right now -- but I doubt it. There is a very large trauma service in Seattle, and I would bet that clinical trials would have taken place there.)

By the way, the local shrimp are delicious and are served peeled (maybe to send the exoskeletons to work as bandages.)

The conference I am attending is called the Nordic Conference for University Hospitals and Faculty Deans, with attendees from Iceland, Denmark, Sweden, Norway, and Finland, and three of us guest speakers from Calgary, Manchester (UK) and Boston. I always worry a bit when I am invited to speak at these things because I have so little knowledge of the field compared to others, but I liked the topic I was assigned. It is "Never let the practice of medicine be replaced by the business of medicine." Of course I agree with that, but I also think part of the topic has to be "Never forget that the business of medicine can affect the practice of medicine."

What´s really interesting is that these countries, which have national health insurance systems, are feeling the pinch more and more from their legislative bodies. Members of parliament are upset with the rising costs of health care and want to see more efficiency and higher quality. The underlying system is not likely to change, but hospital CEOs are expected to deliver more for less, and they look towards our US experience for ideas and suggestions.

I can´t wait to see what I am going to say during my talk tomorrow. If I come back wearing lots of shrimp-laced bandages, you will know that it didn´t go very well.

P.S. I took this picture of a waterfall east of Reykjavik at a World Heritage Site called Þingvellir National Park.

Tuesday, August 21, 2007

On my favorite topic, reporting of clinical results, Theo Francis at the Wall Street Journal talks about ranking of physicians by insurance companies:

Doctors and regulators are pushing back against rating systems that some health insurers have developed to guide consumers in choosing physicians. New York Attorney General Andrew Cuomo demanded last week a "full justification" of the rankings that Aetna Inc. and Cigna Corp. have rolled out in the state. He warned the companies that the ratings are confusing and potentially deceptive, in part because insurers don't disclose how prone to error their rankings are. The move follows rankings lawsuits by doctors accusing insurers of libel, unfair business practices and breach of contract in other states.

A number of insurance company people here in Massachusetts had raised similar concerns with me, stating that any ratings they produced would be viewed as self-serving by members of the public. So, I guess this throws the ball back into the court of the public agencies. (Or, of course, providers could self-report on an insurance company website that was open to all.)

I picked up the telephone last night at home to find one of those electronic surveys on the line. Once I heard the introduction, I stuck with it all the way through just to see what it was about. I´ll describe it, and then people can respond if they know why it was done and whether it is what it says it is.

It started by saying that it was a survey for the state Department of Public Health. There were about two minutes worth of questions, all answerable by pushing a button. It seemed to be about health insurance, and whether I had insurance through my employer or through the new Connector Authority (set up under the new MA health insurance/access law). But then it asked a weird question: Did either of my parents smoke? If so, which, the male and/or the female? It also asked the usual question about my level of education and my age. And then it concluded by saying again that it was a survey for the state DPH.

Of course, I realize that all these surveys, supposedly anonymous, really are not likely to be. After all, they know your phone number, and from that they know your name and address. But that is not what had me wondering.

If it really was the DPH, why are they doing a survey about health insurance? The responsibility for that lies with the Connector Authority, a completely different state agency. And the Connector Authority is already collecting data on how many people in different categories have insurance through their employer or through the plans made available by the Connector. And why ask about smoking in my family history? And, finally, the way the survey announced it was being done for the DPH was just a little off-kilter: It just did not sound like a state agency. Finally, in all the articles about the state budget this year, I never read any coverage about a DPH appropriation for this kind of survey.

So, I wonder if this was really a survey for some company trying to sell insurance or some broker trying to broker insurance sales? As a result of these calls, they could easily segment respondents by age, address (and therefore likely income), family health history -- just what you would want if you were selling health insurance.

Am I too cynical? Maybe someone out there from the DPH will read this and comment. If you are doing the survey, what is it for? If you are not, perhaps you could notify some law enforcement officials that someone is appropriating your name for other purposes.

Monday, August 20, 2007

A recent email, from Stacey, one of our great ICU nurses, about a doctor with visiting privileges from an affiliated institution:Paul,

I have been encouraging and supporting the hospital’s policy regarding hand hygiene. My understanding is that all personnel are to use Calstat when entering or exiting a patient’s room, even if they are not going to give direct patient care. I happened to notice Dr. X entering a room without using the Calstat. I went and politely reminded Dr. X to use the Calstat. Dr. X appeared quite annoyed that I requested him to do so as he said he had already examined the patient and was just looking at the monitor. This is not the first time I have had such encounters. How would you like this type of situation handled in the future?

My reply:

Thank you, Stacey,

You did EXACTLY the right thing, and I appreciate how uncomfortable that can be.

We have indeed asked everybody to remind everybody else about the importance of this matter. As you know, it is very easy to pick up germs from equipment and material near the patients and then pass those along to other patients and staff, even when the doctor or nurse has not actually touched the patient.

I am copying Dr. Sands, our SVP of Health Care Quality, who will now follow up with Dr. X.

Sunday, August 19, 2007

Emily DeVoto has a nice summary of the issues (and the link to the New York Times article) surrounding a possible Medicare rule that would withhold payments to hospitals when hospital-acquired infections occur. Zagreus Ammon also pitches in on the topic, as does John McDonough at Health Care for All.

Turning now to the infrastructure crisis, please read this hilarious -- and totally accurate -- column written by Monique Spencer. She writes about the "traffic calming" measures installed on Beacon Street in her home town of Brookline, MA. An excerpt:

You put a red light on every block. You get rid of parking in order to kill the retailers. You make new pedestrian crossings appear overnight, in between the red lights. Special bike lanes appear on one block, then disappear, with nanny signs that say "Share the Road." Meander the side streets and you'll find giant mounds in the road that are supposed to make you slow down. The traffic engineers call these "vertical deflections." Their real function is to eject the newcomer. At night, he does not see the mound, because it is not lit. He hits the takeoff ramp at 30 miles per hour, and by the time his car touches ground again he is in the next town.

I do not feel calmed.

In a more serious vein, part of the reconfiguration was to remove one lane of traffic to create a protected area for on-street parkers along the median island of Beacon Street -- accompanied by a "bulb-out" or "neckdown" at each intersection (see picture above). Let's please recall that the Brookline section of Beacon Street is one of the evacuation routes from downtown Boston in the event of civil emergency or natural disaster. Now that three outgoing lanes have been transformed into two, it seems that we have a 50% reduction in traffic capacity. Were the emergency preparedness people from Boston notified before this happened?

Saturday, August 18, 2007

The next chapter in the ADL story is splayed on the front page of the Boston Globe today. Keith O'Brien reports: "The national Anti-Defamation League fired its New England regional director yesterday, one day after he broke ranks with national ADL leadership and said the human rights organization should acknowledge the Armenian genocide that began in 1915."

Andy Tarsy, the regional director who did the right thing, has now taught the public an additional lesson: Sometimes doing the right thing costs you personally, at least in the short run. But I predict and hope that Andy will not have to worry for long.

The action by the national ADL organization now turns the focus on the board members of the local ADL affiliate. Presumably Andy had the support of his local board in taking the action he did. A former board member commented to the Globe: "I predict that [these] actions will precipitate wholesale resignations from the regional board, a meaningful reduction in ADL's regional fund-raising, and will further exacerbate the [national] ADL's relationship with the non-Jewish community coming out of this crisis around the Armenian genocide."

Local board members really have no choice but to resign over the firing of their hand-picked executive director. But these are highly committed volunteers and community leaders who strongly believe in the mission of the ADL. What's for them do to in support of that mission?

The clear answer is to resign, rescind any philanthropic commitments they have made to the national ADL, immediately create a new regional organization with precisely the same mission, hire Andy back, and go to work rebuilding support throughout New England for the important programs they have been running.

[Disclosure: Andy's father is a member of the faculty at BIDMC, but I have not consulted with him on any of these blog postings.]

Addendum on August 19. In writing this, I didn't mean to suggest that local board members who choose to stay on the board and try to work changes in the national ADL should be faulted at all. That is an alternative approach that deserves a lot of credit. It is, however, a long row to hoe -- and until it all gets worked out, I am guessing it will be hard to find a person willing to be a successor for Andy at the New England regional branch.

Friday, August 17, 2007

My friend Dave sent me notice of a new blog, called In Sickness and In Health, "a place for couples going though an illness experience - to share stories, advice, resources, and to learn from each other." It's by Barbara Kivowitz. Dave says, "She writes well, has a lot to talk about, and ought to attract an audience, I think." Let's help her along.

Thursday, August 16, 2007

I am prompted to write on this issue after being awakened to it by a stirring talk I recently heard by Rabbi Ronne Friedman at Boston's Temple Israel.

Back in May, I wrote a post congratulating the Anti-Defamation League on their World of Difference program. This is a thoughtful and well-intentioned program to teach schoolchildren ways of avoiding prejudice.

Recently, the ADL has been involved in a major controversy about the genocide of Armenians by the Ottoman Empire in the early part of the last century. There is a good description of the dispute on Blue Mass Group.

I fear that ADL has lost its way on this issue, refusing to support a Congressional resolution that calls the massacre what it was, genocide. Now they try to rationalize their failure. See these words of their local civil rights counsel:

The Jewish community in Turkey has clearly expressed to us and other major American Jewish organizations its concerns about the impact of Congressional action on them, and we cannot ignore those concerns. We are also keenly aware that Turkey is a key strategic ally and friend of the United States and a staunch friend of Israel, and that in the struggle between Islamic extremists and moderate Islam, Turkey is the most critical country in the world.

Compare that to the pledge students are asked to take at the end of the ADL's World of Difference Program:

I pledge from this day onward to do my best to be aware of my own biases against people who are different from me. I will ask questions about cultures, religions, and races and other individual differences that I don't understand. I will interrupt prejudice and speak out against those who initiate it. I will reach out to support those who are targets of harassment. I will identify specific ways that my peers, my school, and my community can promote greater respect for people and create a prejudice-fee zone. I firmly believe that one person can make a world of difference and that no person can be an "innocent bystander" when it comes to opposing hate.

I know this pledge is not exactly on the point of the current dispute, but its message is close enough. The pledge does not say that I will stand up against prejudice only when it is politically convenient to do so or only when it is risk-free to do so. Or that I will shy away from controversy for fear of offending an important constituency.

Rabbi Friedman reminded me that Adolf Hitler used the genocide of the Armenians as part of his rationale for destroying other groups. Here's the quote he read.

Our strength consists in our speed and in our brutality. Genghis Khan led millions of women and children to slaughter — with premeditation and a happy heart. History sees in him solely the founder of a state. It's a matter of indifference to me what a weak western European civilization will say about me.

I have issued the command — and I'll have anybody who utters but one word of criticism executed by a firing squad — that our war aim does not consist in reaching certain lines, but in the physical destruction of the enemy. Accordingly, I have placed my death-head formations in readiness — for the present only in the East — with orders to them to send to death mercilessly and without compassion, men, women, and children of Polish derivation and language. Only thus shall we gain the living space (Lebensraum) which we need. Who, after all, speaks today of the annihilation of the Armenians?In simple language "annihilation" of a particular ethnic, religious, or social group is "genocide." Hitler knew exactly what he was saying.

Nothing can bring back those who died. The government that was in power at the time is long gone, too. But the surviving people of Armenian descent -- along with every other group that could possibly be the target of genocide -- deserve the support of the ADL in validating what really happened in 1915.

If the national office of the ADL remains recalcitrant on this issue, the New England Region should break ranks and make an alternate position clear.

(By the way, here's the text of the disputed Congressional resolution: Calling upon the President to ensure that the foreign policy of the United States reflects appropriate understanding and sensitivity concerning issues related to human rights, ethnic cleansing, and genocide documented in the United States record relating to the Armenian Genocide, and for other purposes.)

Addendum. Breaking news on August 17: The New England chapter did indeed break ranks. Bravo to them!

I discussed below the results of the unannounced survey by our accreditation body, the Joint Commission. We are also subject to inspections by other regulatory agencies. One is conducted by the Food and Drug Administration, to ensure that our handling of blood products (i.e., blood banking and transfusion) is carried out in accordance with federal standards. The inspections are completely unannounced. There are no black-out dates, so we are not given blocks of time for which we can expect an inspection.

The standard enforced by the FDA is called "current Good Manufacturing Practice" (cGMP). The rules of cGMP cover areas such as organization and personnel, facilities, equipment, supplies and reagents, standard operating procedures, labeling, compatibility testing, records, adverse reaction files, and deviation reporting. The goal, of course, is to ensure that the blood products we collect from donors, process, crossmatch, and transfuse to our patients high certain standards for safety, purity, potency, and labeling.

Our unannounced inspection started on August 7. The inspector spent 5 full days touring our facilities, interviewing staff in our Pathology Department and on the floors, observing operations, and reviewing documents and records. By touring the blood banks and the Infusion & Pheresis Unit, the inspector checked to see that our facilities were clean and orderly. During this inspection, the inspector observed an autologous whole blood donation in the Infusion & Pheresis Unit. In the blood bank, she observed our processes for receipt of blood from our outside blood suppliers as well as our processes for management of our inventory, including confirmation of the blood component ABO and Rh type. Additionally, she reviewed the functionality of our blood bank computer system related to product testing, patient testing and product distribution for transfusion.

The inspector also checked for proper storage and handling of blood products. Blood storage refrigerators and freezers were audited for proper temperature and proper labeling and segregation by ABO and Rh type. Records of temperature monitoring and alarm conditions were reviewed to ensure that products were maintained at the proper temperature at all times. Disposition records were reviewed to ensure that products not suitable for transfusion were destroyed.

Written standard operating procedures were also checked for evidence of timely reviews. Training records of new employees were reviewed, as were quality control records of equipment, such as the blood irradiator, and also for reagents used in blood typing and compatibility testing.

I am pleased to report that the FDA inspector found no reportable issues or recommendations. We are quite pleased with this result. We always want to be able to assure our patients that blood products they receive at this hospital have been prepared following good manufacturing practice in order to ensure the products’ safety, purity, and effectiveness.

Wednesday, August 15, 2007

A recent informal survey we conducted indicates that more people know BIDMC is a teaching hospital of Harvard Medical School (52%) than know we are the Official Hospital of the Boston Red Sox (36%). However, we have been the former since the 1920's and the latter only for five years. This suggests to me that there is a relative lack of staying power in the Harvard name. I've put in a call to the administration at Harvard with some suggestions as to how they could enhance their brand identity. I left three options on President Faust's voicemail:

1) Merge with and leverage off the reputation of another university. My suggestion was MIT.

2) Purchase the Red Sox and move the main administrative office of the university to the snack bar on the Green Monster at Fenway Park, where it will be seen every time Mike Lowell or Manny Ramirez hits a home run.

Tuesday, August 14, 2007

Being new to hospitals -- and being pretty oblivious to what they were like 10 years ago, much less 30 -- I recently learned something amazing. This will not be new to many readers who are above a certain age and spent time in hospitals, but for me it was a stunning revelation.

As late as the 1970's, the Boston hospitals -- including BIDMC -- had service wards. These were full floors of beds dedicated to those members of the public from lower income groups without insurance. Then, there might be different parts of the hospital with two or three patients to a room for the slightly better off. Finally, there would be private rooms for the well-heeled.

Corresponding to the bed layout, the service wards were staffed entirely by residents. Attendings, i.e., full-fledged doctors, would only serve the well-to-do patients. (By the way, emergency rooms were also totally under the authority of residents.) Nursing ratios, too, varied by income level. Our current Board Chair, Lois Silverman, told me of being a young nurse with total responsibility for 30 patients on a service ward!

Here is a marvelous description of this at Massachusetts General Hospital, written by Dr. Jerry Groopman, who was an intern there in 1976. (I include this as representative of the general situation because it is so nicely written, and not at all to reflect solely on MGH.)

There were three clinical services, Bulfinch, Baker, and Phillips, and over the ensuing twelve months we would rotate through all of them. Each clinical service was located in a separate building, and together the three buildings mirrored the class structure of America. The open wards in Bulfinch served people who had no private physician, mainly indigent Italians from the North End and Irish from Charlestown and Chelsea. Interns and residents took a fierce pride in caring for those on the Bulfinch wards, who were "their own" patients. The Baker Building housed the "semi-private" patients, two or three to a room, working- and middle-class people with insurance. The "private" service was in the Phillips House, a handsome edifice rising some eleven stories with views of the Charles River; each room was either a single or a suite, and the suites were rumored to have accommodated valets and maids in times past. The very wealthy were admitted to the Phillips House by a select group of personal physicians, many of whom had offices at the foot of Beacon Hill and were themselves Boston Brahmins.

Who would have thought that, only 30 years ago, equal access meant separate and not at all equal? Today, we when talk about equal access to health care, we actually mean equal. At BIDMC, care is truly delivered without regard to income. A Stoneman or Feldberg descendant from Back Bay or the western suburbs might be in single or double room in the Stoneman or Feldberg building named after their parents or grandparents -- but so might a Smith or Jones from Dorchester, Mattapan, or Roxbury. The staffing ratios -- residents and attendings and highly trained nurses -- are the same, the housekeeping is the same, the food is the same (room service!), and all the televisions show the Red Sox on channel 26, and have those cumbersome TV remote controls.

Full disclosure: The only physical amenity that is left to those who choose to pay extra is to acquire a single room when there is not the medical necessity for a single room. This is only permitted when such rooms are available. Otherwise, they are allocated first to those cases requiring isolation, and then generally assigned to other patients.

Liz Cooney reports on White Coat Notes that Tufts Health Plan, Harvard Pilgrim Health Care, and Blue Cross Blue Shield of MA all received excellent ratings in a Consumer Reports reader survey. She notes, "The health plans were judged on how satisfied respondents were with the choice of doctors, care from doctors, access to doctors, primary-care doctors and billing."

Congratulations to all three companies, all of whom provide excellent service to their customers. Not to take anything away from their accomplishments, but since none of them actually provide medical care, perhaps the doctors and hospitals in Massachusetts also deserve some of the underlying credit for their successful survey results.

Monday, August 13, 2007

Imagine the buzz this would cause: Ford Motor Company announces a search for the head of its new mid-sized car division. The search committee comprises the comparable division executives from Toyota, Honda, General Motors, and Chrysler.

Well, what would be odd elsewhere is the norm here at the Harvard hospitals. As I have explained elsewhere, the Harvard medical system has an odd assortment of customs and norms. One of oddities surrounds the search for a chief of any of the clinical departments at BIDMC, MGH, Brigham and Women's, Children's Hospital, and the other Harvard affiliates.

For example, we will soon start a search for a new chief of OB/Gyn, as our Dr. Ben Sachs goes off to be Dean at Tulane Medical School. Without a doubt, the heads of the OB/Gyn departments at the Brigham and MGH will be invited to serve, along with some senior level faculty from BIDMC. The actual committee is formally appointed by the Dean of Harvard Medical School, with advice from his Council of Academic Deans representing the major Harvard affiliated hospitals.

The Dean, you say? But the new chief reports to the hospital CEO and is paid by the hospital and its faculty practice, not by the Medical School. Where does the Dean come in? Well, the new chief will not only be chief of service at our hospital but will also be head of the BIDMC Department of OB/GYN at Harvard Medical School. In that capacity s/he has certain academic responsibilities. For example, the executive committee of the three chiefs of OB/Gyn reviews academic promotions in their field (in any of the three hospitals) and could collaborate on areas like graduate medical education programs.

As CEO, I also get to serve on the search committee, which also -- somewhat paradoxically -- makes it recommendation to me -- and also to the Dean.

I hope this is now totally clear to you.

By the way, have I reminded you that HMS and Harvard University do not own any of the affiliated hospitals? We are all 501(c)(3) nonprofit organizations that are totally separate, in terms of governance, charter, and finance, from Harvard. (This last point is probably something about which the president of Harvard wakes up each morning and says, "Thank you, Lord." Among other things, it means that we do not have access to that wonderful endowment portfolio, which would otherwise come in really handy when the new Medicare rates are announced each year.)

Now, I am sure that the entire arrangement is totally clear to you. If not, start at the top and try it one more time.

Friday, August 10, 2007

A I mentioned a couple of weeks ago, BIDMC had an unannounced visit from the Joint Commission. At the time, I promised you that I would publish the results of that review. Following is the email I sent to our staff today. Here again is the link to the full report.

Dear BIDMC,As many of you know, we recently had a visit from the Joint Commission, the organization that accredits all of the hospitals in America. The surveyors from the Joint Commission spent several days here in intense review of our physical facilities, our information systems, and -- most importantly -- our actual delivery of care to patients. As is the current practice, this was an unannounced visit, with the surveyors showing up on a Monday morning with just a few hours notice. The people who came were excellent, thoughtful, and comprehensive. As I will discuss below, they found some things that needed improvement, but they also had many compliments for the hospital in general and for many, many of you in particular. They were struck by how many of you came up to them to explain what you were doing and to demonstrate our clinical approaches and advances.

I want you to have the advantage of their work product, so I have posted it on our website. Please read it. Here's the link: http://www.bidmc.harvard.edu/JC07_report. As far as I know, this is the first time that a hospital has made its Joint Commission report available to the entire staff and to the world at large. Doing so is consistent with our approach to quality and safety matters here at BIDMC. We believe that sunshine is the best disinfectant!

To summarize, there were three types of areas in which the surveyors asked us to make improvements: clinical process, infrastructure, and administrative. In all, they found eight areas for required improvements. I am not going to go through all of those here, since you can read them yourselves, but let me hit a few highlights as I see them.

First is medication reconciliation. We have the most advanced clinical support systems to help providers ensure that they know the full range of medications being taken by a patient. Our electronic medication reconciliation system enables any clinician, at every encounter, to review all the medications a patient is taking, then verify they are correct or modify them to indicate that the patient is not taking them. Additionally, we can record medications provided at an outside institution, document over the counter medications purchased at a drug store and even record medications with uncertain dosages that a patient reports receiving from other providers. All of this information is used to perform safety checks such as drug/drug, drug/allergy and drug/food interactions.

(By the way, in September we go live with a cutting edge medication history system that will display dispensed drug history from every pharmacy and insurance company in New England. This system, part of MA-Share e-Prescribing gateway, will check drug/drug and drug/allergy interactions among every medication a patient has ever received from any clinician in our region, including medications prescribed by Partners Healthcare, Lahey, Caritas, and private practices.)

But a system like this is only as good as it is being used. The Joint Commission surveyors found that there was uneven use of this powerful system by our doctors and suggested that we enforce it hospital-wide. We agree totally. While many doctors use the system daily, others have avoided it. This is probably understandable, in that some doctors like to be "early adopters' and others are a bit slower to utilize new technology. Over the coming weeks and months, we will make use of the system mandatory.

A second area is the history and physical exams that are performed on patients before surgery. Here, we had a certain system in place, but we learned during the survey that our approach was not quite in compliance with the current Joint Commission standard. Once the surveyors pointed this out, we immediately corrected it, and we believe we are now in conformance with the current standard.

A third area was the security of medications in our code carts, both on the floors and in the supply assembly areas. Certain medications need to be protected so they are not available and stolen or misused. We are fixing this.

On the infrastructure front, the surveyors found a variety of items. For example, some gas canisters were not properly secured. This is a true public safety hazard. If an unsecured gas canister falls and the regulator breaks off, the heavy tube can be an uncontrolled projectile. Another example is that several of our fire doors had gaps of greater than 1/8 inch between the door and the door frame. Again, a public safety hazard that we will fix.

The next step in this process is that we have 45 days to submit plans for required areas of improvement to the Joint Commission. We are also permitted to appeal the surveyors' report if we think that they were in error on one point or another. That sometimes happens because, notwithstanding good intentions, the surveyors cannot necessarily get a full picture of all items during a one-week visit. We are likely to appeal one or more of the areas that were found to require improvement. This does not mean we would avoid actually making improvements in those areas -- it would only mean that they would not be a formal requirement for our re-accreditation.

The upshot is this. We did very, very well. On average, the Joint Commission finds 10 or more requirements for improvement in their hospital surveys. We had eight. Our re-accreditation is secure. The areas in which they found us wanting were legitimate and proper, and it is our job to fix them. The good news is that we were not surprised. Most of the areas they pointed out were on our agenda to fix over the coming months as part of our continuous improvement efforts.

I have often said that, if the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public. I want to thank the hundreds of you who interacted with the surveyors in such an open and positive way during their visit, and to the thousands of you who were ready to do so.

Thursday, August 09, 2007

While we have spent a lot of time here and in the media in the last few days and weeks discussing the merits of public disclosure of hospital infection rates and other quality metrics, we have neglected discussion of the role of a hospital's governing body in holding the medical and administrative staff accountable for patient safety.

Back in February, I talked about the role of the hospital's board of trustees in governing safety and quality. The board does have final authority for these matters under state law. How it should do the job is not specifically set forth in the law. A lot of what I presented in my February posting was suggested by an external review committee we had retained for BIDMC to evaluate our safety and quality programs.

One member of that review committee was Jim Conway, former COO of Dana Farber Cancer Institute, and now working at the Institute for Healthcare Improvement and teaching part-time at the Harvard School of Public Health. Jim recently had an interview with an organization called Great Boards. It is well worth reading, and I link to it here.

As I read through his recommendations, I see that we have implemented some of them, but some items are left to be done. For example, over 25% of our board meetings are devoted to these topics, and we present specific cases of where we have done harm to patients and what we have learned and changed as a result. In October, we are holding a two-day board retreat focused solely on this topic. Our board members will participate in on-site visits of patient care areas -- talking with doctors, nurses, transporters, and others -- will review Jim's recommendations and others, and then they will decide how they want to govern quality and safety at BIDMC going forward. I know that similar discussions are taking place at several other hospitals in the region.

But here's a question for the public debate: Should the state DPH, which has authority over public health matters, or the Attorney General, who has supervisory authority over public charities, require some certification of board of trustee training in safety and quality matters? We could not imagine a doctor or nurse being permitted to serve the public without training. Should board members who have the statutory responsibility for patient welfare also be required to meet some minimum level of competence in this regard? I am not suggesting they would need to have the technical depth of MDs or RNs, but perhaps they should be required to have a working knowledge of the governance issue surrounding quality and safety.

Wednesday, August 08, 2007

Jessica Fargen, on the Boston Herald blog, reports that the state Public Health Council, the policy board for the Massachusetts Department of Public Health, is weighing a set of recommendations that would require every hospital in the state to report certain hospital-acquired infection rates to the public or to a state-sponsored agency. In particular, the public would get to see bloodstream infections associated with central venous catheters in ICU patients; surgical site infections from hip and knee replacements; and rates of influenza vaccination of health care workers.

I have not yet seen the details, and I am a bit unclear about what happens to these recommendations now that they have been presented, but this is clearly a step in the right direction. (For BIDMC, you can already see some of these numbers and lots of other ones, too. We are happy to share our experience in posting these data with any who are interested.)

By the way, when I proposed similar ideas back in February, I was characterized by some of my colleagues as attempting to create a marketing advantage for BIDMC and/or proffering bad information to the public. I hope these recommendations by the PHC will lend credibility to the usefulness of this kind of disclosure and will help eliminate the feeling that we were guided by selfish motives.

Addendum on August 9: Stephen Smith also has a story in today's Globe on this topic. Check out this quote:

Christine Schuster, president of Emerson Hospital in Concord, said that hospitals across the state have already begun to track infection rates internally and that, increasingly, administrators are accepting that they need to make their operation more transparent in order to foster patient trust.

"At first, you might think, 'Oh, my gosh, I don't want to put my numbers up there.' But let's be honest: There's a tsunami coming out there regarding public reporting and transparency," Schuster said. "You can stand on the shore and get washed away, or you can get on board."

Tuesday, August 07, 2007

In every room, we have a white board that is supposed to be used by the nurse on duty to note his or her name and other pertinent information for the patient and the patient's family. It is a handy, low-tech reference tool that is very helpful to people during their stay in the hospital.

Here is a note to me from a family member of a patient recently discharged. I am hoping nurses in our hospital and elsewhere will take something useful from this comment.

I noticed something funny during this hospital stay -- the white board has taken on an interesting life of its own. We had a nurse who did not use it. She turned out to be the kind of nurse who makes you nervous that she's not paying attention -- you know, the pain killer dose was not written in when it was given, that kind of thing. Then we realized: We felt that way from her first entry to the room, when she did not "sign in." It really is an interesting little step that makes you feel good. I don't understand it, but I sure like it.

For social media neophytes, Jessica Lipnack directs us to a website with really neat, informative, and funny mini-videos describing things like wiki's. Those with lots of experience will also find them very entertaining. Check them out.

Monday, August 06, 2007

Best comment from a spectator (at about mile 70) along the route of the Pan-Mass Challenge: "Cold water -- and a chair if you want it."

As you ride along in an event like this, with several thousand people supporting cancer research at the Dana Farber Cancer Institute (by riding, by volunteering, by waving and applauding at the riders coming by, and by donating money), you have to wonder why it works. Many people have written about Americans being joiners, particularly where a philanthropic cause is involved. That might be part of the story, but I think there is something more here.

Anyone who has experienced cancer personally or through a friend or loved-one knows how pervasive an impact it has on the lives of both the patient and everyone around him or her. More than any disease, it seems to incite a team of people to become engaged in fighting it. And the team spreads beyond the immediate circle of friends and family to include other circles of friends and families.

As you ride, volunteer, attend, or donate in the PMC, you are swept into this amazingly large circle of people wanting to eliminate this disease. There is a cocoon-like feeling to the two days, as though the rest of the world has disappeared and you are surrounded by and absorbed into a close-knit group of thousands of close friends. Every rider you pass or passes you, and every spectator along the route, and every volunteer at a rest stop is part of a warm and thoughtful and caring group, supportive of one another, but seriously joined together as a intense phalanx against this disease.

The young boy at mile 70, and thousands of others en route, yell out "thank you" to the riders. That's what pushes these bicycles along. It's not the months of training before the ride or the gallons of Gatorade on a hot day in August. It's knowing that those people on the street have felt or seen cancer in their lives and that they view the folks on the bicycles as part of the forward line in hunting down this enemy.

Meanwhile, we know that dedicated scientists at DFCI and throughout Boston and the world are really doing the hard work. But for just a few hours, we all get to join with them.

Friday, August 03, 2007

Off duty for the weekend to ride the PMC with several thousand of my closest friends. Please find a rider to support if you have not already done so. This is an excellent program to fund research at our sister institution, Dana Farber Cancer Institute.

Thursday, August 02, 2007

A very small percentage of hospitals in the country -- about 10% -- have computerized provider order entry (CPOE) systems for medication orders. This kind of system eliminates hand-written orders and has features that warn against drug-drug interactions. It also helps reduce medical errors because the computer is programmed with strict parameters that make it very hard for a provider to make a dosage mistake.

Until a few weeks ago, no hospital in the country (to the best of our knowledge) had a CPOE system for dispensing chemotherapy drugs. Now, BIDMC does. Over the past year, we've completely automated chemotherapy ordering with our Oncology Management System.

Here's how it works. Research nurses and oncologists agree upon protocols for best practice cancer care. When a specific patient is to be treated, clinicians order the relevant protocol -- which then is automatically optimized for the patient based on his or her height, weight, and kidney function. Since doctors order a care plan and not specific medications, the accuracy of all chemotherapy doses and all related orders is guaranteed. So far the system is in place for outpatients. We plan to be in operation for inpatients within a few months.

This is a self-developed system. Our CIO, John Halamka, and his staff work closely with doctors and nurses to design a system that meets the needs of the providers in the hospital. Everything, including the look and feel of the ordering screen, is developed by the geeks with input from doctors and nurses. (Yes, we also purchase vendor-supplied applications when they have what we need, but often they are not available or not suitable for these leading edge applications.)

Today is the first anniversary of this blog. Here's the link to the first post. There have been over 300 since then on every topic imaginable.

My favorite posts used to be the ones where I thought I wrote something with great insight or excellent prose, but I have come to really enjoy the ones where people out there take the time to post comments. Also, there have been several that have actually led to real (i.e., not cyberspace) relationships with folks I would not have otherwise met. Some of those people are actually Yankees fans.

Special thanks to Chris Rowland at the Boston Globe who really helped this site take off by publishing an article about it last fall. Until that moment, it was hard to detect this blog when I did a web search, and my friends were getting awfully tired of my reminding them to check in and spread the word so that Google would know I existed. Thanks, too, to all of you who have linked to this site on your own blogs and to the many writers with journals, magazines, and newspapers who have referenced this blog in their publications.

Thanks to all of you for your readership, whether dedicated or sporadic. You are generous in sharing your precious time and your points of view with me and others.

Special thanks, though, to those people who choose to post using their real names. Although I have always welcomed anonymous posts, I especially admire people who are willing to identify themselves when they put their views out there for all the world to see. America has always welcomed public and open commentary on matters of community interest. The tradition of the public soap box, upon which any person could rise and speak his or her mind, is inherent in our form of government (something we borrowed it from Great Britain). For those who like to post anonymously, please understand that your thoughts carry more import with readers when you identify yourself. Try it. It is a very freeing experience. Hey, if I can post the things I have with everybody knowing who I am, you can probably do the same most of the time.

Of course, if you live in Boston and are one of those Yankees fans, it is probably wiser to retain your anonymity.

Wednesday, August 01, 2007

Just a random observation following some of our previous discussions about using websites to disclose hospital infection rates and other consumer-oriented information. Some of the comments I received at the time argued that the public could not be expected to understand such technical information.

I'm presently at a conference and using a computer in the hotel's business center. On the menu bar of the installed browser are shortcuts for the following topics: incontinence, senior health, prostate, menopause, health, and prescriptions. This reminded me that -- after pornography -- medicine- and health-related websites get the most traffic on the web.

So, part of the issue we in health care face is this. Do we want the public only to get their information from commercial and other types of websites included in categories like the ones above -- or do we want to offer them thoughtful alternatives from the people who actually deliver care? If we are overly cautious in what we allow to be published about our institutions, we cede this medium to others who do not necessarily all have the standards of care and ethical values that we like to exemplify. Shouldn't we worry about "the perfect being the enemy of the good?"